HomeMy WebLinkAboutApp-Permit-ComplianceNo. 660C417— `" FEE
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( f- l d ®&ONWEALTH ®F MASSAC14US ETTS A
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7 / 114 �oard of Health, t MA. �V-/-% 9" mss '
LIGATION FOP, DISPOSAL SYSTEM[ CONSTRUCTION ERMIT
Application for a Permit to Construct( ) Repair (/Upgrade( ) Abandon( ) - Ll Complete System Individual Components
Location
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Owner's Nam�s<
Map/Parcel# .,
Addresses.
Lot# -�2 6i -Telephone#
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Installer's Name
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Designer's Name`s
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Address .A��„I
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Address/)- 0
Telephone#
Telephone#
7 26
Type of Building �fo/2-�s�l`�y Lot Size /G; 47/9 sq. ft.
Dwelling - No. of Bedrooms Garbage grinder( )
Other - Type of Building No. of persons Showers ( ) , Cafeteria ( )
Other Fixtures
Design Flow (min. re uired)2�1J gpd Calculated design flow Design flow provided 33 gpd
Plan: Date X39 Number of sheets 3 Revision Date
Title
Description of Soil(s) r�%ue G S�� url 3,:p
Soil Evaluator Form No. Name of Soil Evaluator Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS rAdl/ 1 o O 4 a/� i�-� o .l �rG�°r/� G `r Qwift”
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The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees tuLpot to place the system in operation'until a Certificate of Compliance has been issued by the Board of Health.
Signed 4:; /
� Date �, 4 9
InspectionsS111 / 1 s'o 15 -0
No. Fil�%�Lx�EE
MASSACHUSETTS
Board of Health, 6K
CERTIFICATE OF COMPLIANCE °� `
Description of Work:dividual Component(s) ❑ Complete System
The undersigned hereby certify at the Sewage Disposal System; Constructed ( ), Repaired (Upgraded 0, Abandoned ( )
at Y Ci O/tel
has been installed in accordance with the proyisio s of 310 CMR 15.00 (Title 5) and the approved design plans/as-built-plans relating to
application No. _ dated e*111 Approved Design Flow 7 ---ff(gPd) y
Installer _ -
Designer: Inspector: Date:
The issuance of this permit shall not be construed as a gu tee that the system will function as dei igned.
No. 66ft't ` it C[7 sF}j�c.jC�-�1�E� FEE
f14F COMMONWEALTH OF MASSAC14USETTS
Board of Health, MA.
DISPOSAL SYSTEM CONSTRUCTION. PERMIT
Permission is hereby granted to; Construct( ) Repair( Upgrade,( Abandon ( ) an individual sewage disposal system
at �J i '% r ee.:rte O i/i ✓' - /, �1 as described in the application for
Disposal System Construction Permit No. , datedlf4 t'
Provided: Construction shall be completed within three years of the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Boston, MA Date "T Board of Health CJ
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